“The pink pulseless hand”—not a benign condition. Neurovascular compromise in paediatric supracondylar fracture of the humerus

Abstract

<h3>Aims</h3> Supracondylar fracture of the humerus is the most common upper limb fracture in children, accounting for 70% of elbow fractures. There is a high incidence of associated neurovascular injury and management of these cases is much debated, particularly indications for surgical exploration of the antecubital fossa in a pulseless, but clinically well-perfused hand. Several publications have suggested that the “pink pulseless hand” is a benign condition that can be managed expectantly and exploration need only be undertaken if there are further signs of neurovascular compromise. This study aims to assess whether this is a safe message. <h3>Methods</h3> A retrospective case note review was undertaken of cases of paediatric supracondylar fracture requiring manipulation/fixation from January 2000 to July 2009 in a regional vascular unit. Medical notes were analysed, focusing on neurovascular compromise and complications. <h3>Results</h3> The age range of children was 2–13 years. 25 children sustained a fracture requiring reduction. Five (20%) did not have a palpable radial pulse, but had a well-perfused hand. Two were immediately explored as compound fractures. Both required brachial artery repair and one median nerve release. The antecubital fossa was explored in two of the remaining three cases (one with documented normal neurology and one with no neurological status documented). Both required brachial artery repair, one median nerve release and one a fasciotomy. The final case was initially managed conservatively and developed a persistent median nerve palsy and ischaemic forearm contracture leading to significant disability. Thus, three of the five children with a pink pulseless hand had nerve entrapment and one developed ischaemic complications due to failure to explore the brachial artery. All explored brachial arteries required repair. One child who underwent exploration developed a hypertrophic scar. <h3>Conclusion</h3> The pink pulseless hand is not a benign condition that can be managed conservatively, but rather should be recognised as an indicator of likely neurovascular compromise. Any message suggesting otherwise, leads to the unacceptable risk of missed neurological injury, nerve ischaemia and muscle ischaemia leading to contracture and subsequent disability. Unless there is a compelling reason not to explore these cases, the brachial artery and associated nerves should be released routinely.